Improving the Patient Experience through Experience Based Design

1 Improving the Patient Experience through Experience Bas...

Author: Nancy Willis

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1 Improving the Patient Experience through Experience Based DesignSouth East LHIN Primary Healthcare Forum October 6, 2016 Morning Learning Session

2 Objectives To provide an overview of the Experience-based Design (EBD) Methodology developed by the Institute for Innovation and Improvement in the UK. To explore the key concepts integral to the method for capturing & understanding the patient/family experience, and effectively co-designing improvements with them. To share the experience of organizations that have embedded EBD into their organizational approach to Quality Improvement.

3 Strengthen the roles of patients and caregivers in planning careImprove the sharing of health information for patients, caregivers and care providers Improve ability of patients to find and access primary care when needed Strengthen the roles of patients and caregivers in planning care Increase communication among providers, patients and caregivers Maintain high-quality health care services for patients during transitions Gives LHINs and MOH authority to establish one or more Patient/Family Advisory Committees

4 Health Links: Ontario’s ambition for change…Health Links, Nov 7, 2012 Stakeholders have told us that delivering on this agenda, including the right care at the right time in the right place, requires that patients and providers work together more closely than they have in the past. Our partnerships need to include the person at the centre, primary care providers and community partners. Patients need to be part of the transformation as they experience the system and know better than anyone where and how the system can improve. Business Plan Requirements: Section 3.0 – Patient/Family Engagement “Engagement of patients/families is a key component of the Health Link mandate.” Describe how you will engage them (advisory groups, surveys, governance tables, other activities)

5 EXCELLENT CARE FOR ALL ACT, 2010ONTARIO REGULATION 187/15 made under the EXCELLENT CARE FOR ALL ACT, 2010 Made: June 11, 2015 Filed: July 2, 2015 Published on e-Laws: July 2, 2015 ANNUAL QUALITY IMPROVEMENT PLAN Every health care organization shall engage the patients and former patients of the organization and their caregivers in developing its annual quality improvement plan, and the publicly available version of the annual quality improvement plan must contain a description of the patient engagement activities of the health care organization and of how these activities inform the development of the health care organization’s quality improvement plan. Commencement This Regulation comes into force on the later of September 1, 2015 and the day it is filed. Made by: Eric Hoskins Minister of Health and Long-Term Care Date made: June 11, 2015.

6 Accreditation Canada Qmentum Leadership Standards – July, 2014Founded on IFPCC’s 4 Values: Dignity & Respect, Information Sharing, Participation, Collaboration 1.3 Leaders identify client & family-centred care as a strategic priority 1.4 Leaders support teams in their efforts to partner with clients & families in all aspects of care (Policies/Care Plans/Process Improvement) 3.3 Leaders support staff, Board, & Clients/Families to develop knowledge & skill necessary to be involved in quality improvement ROPs focused on client/family involvement in designing incident reporting/analysis/disclosure processes & involvement in designing med reconciliation processes

7 Accreditation Canada Medicine Services Standards: January 20161.1 Services are co-designed with clients/families…. 8.2 The assessment process is designed with input from clients & families Quality improvement initiatives are regularly evaluated for feasibility, relevance and usefulness with input from clients/families Entire set of standards requires that there be input & feedback from clients/families at every stage!

8 Continuum of Engagement Organizational Design & GovernanceLevels of Engagement Consultation Involvement Partnership & Shared Leadership Direct Care Patients receive information about diagnosis Patients asked about treatment plan preferences Treatment decisions based on pt. preferences, evidence, clinical judgment Organizational Design & Governance Organization surveys patients about their care experience Organization involves patients as advisors or advisory council members Patients co-lead safety and quality improvement committees Policy Making Public agency conducts patient focus groups to ask opinions about an issue Patient recommendations re: research priorities are used by public agency for funding decisions Patients have equal representation on agency committees that make decisions on funding for health programs Adapted from Carman KL et al. (2013) Patient and Family Engagement: A framework for understanding the elements and developing interventions and policies, Health Affairs, 32(2),

9 3 Ways to Do Quality ImprovementDon’t listen very much to our users, & we do the designing Listen to our users, & then go off with them to do the designing Listen to our users, then go off to do the designing (Professor Paul Bate 2007) Where do you think you are on this continuum? Can you articulate any examples of the third scenario: Listening to users and then co-designing change with them

10 Reflections from Virginia Mason:Patient: An honour to be involved in this work Took me a while to speak up and realize that I had something to contribute to making care better Privilege to have my voice valued equally Physician: An awesome experience, inspiring, uplifting Wrote to the President of the hospital to say it was the most amazing and humbling experience he has ever had in his professional life Realized that some of what he spends time doing with patients doesn’t really matter to them, but there are other things he has never paid attention to that really matters

11 Experience Based Design is about designing better experiences…

12 What’s different when organizations use EBD alongside usual QI methods?What are we trying to accomplish? What changes can we make that will result in improvement? How will we know that a change is an improvement? Use qualitative CAPTURE tools to UNDERSTAND touchpoints and possibly root cause from a patient perspective IMPROVE & MEASURE: Consult with patients re: acceptability/ feasibility of design from a patient perspective IMPROVE & MEASURE : Debrief with patients to understand whether the test had a positive impact on their experience Use qualitative CAPTURE tools to identify evidence that patients perceive this issue to be a problem Bring patients and providers together to brainstorm/CO-DESIGN change ideas to address root cause(s) EBD Project Set-Up Diagnostic Solution Generation PDSAs Development PDSAs Testing PDSAs Implement-ation Provider: fishbone, Process mapping, Data analysis, etc Occasionally include a patient in a process mapping exercise Provider: Research for leading practices & brainstorming generally done only with providers Provider: Generally get feedback from other providers re: feasibility, format, content, etc Provider: Testing on patients Provider: Spread to all staff in micro-system Problem Identification Articulation of Aim Identification of Measures & Initial Data Analysis Staff QI May start with Quantitative data provided by patients

13 The EBD approach provided an early evidence base and practical guidance.A book written by the researchers Practical Guidance Evaluation of the pilot Peer reviewed paper © NHS Institute for Innovation and Improvement 2009

14 Safety: the story of the toilet roll holderAsk at this point if they can think of any change initiatives that have not worked out as anticipated, and what do they think might have changed if they had engaged patients in a meaningful way to understand their experience and co-design the planned change with them? © NHS Institute for Innovation and Improvement 2009

15 A B C D E Before we get into the approach, a quick survey…How satisfied are you with your ability to influence your own work schedule? A B C D E Very Good Very Poor © NHS Institute for Innovation and Improvement All rights reserved.

20 What was your experience like clearing your schedule to be here today?Another quick survey… What was your experience like clearing your schedule to be here today? A B C D E Very Good Very Poor © NHS Institute for Innovation and Improvement All rights reserved.

25 Experience Based Design is about designing better experiences…

26 Service Providers – Understanding the ProcessESS Support Services

27 Patient/Caregiver Emotional MappingESS Support Services INTAKE ASSESSMENT TRIAL VISIT WAITING FIRST DAY “Had impression that it would stat sooner” “Quite a bit of paperwork but was warned about it” “It’s like watching your kids go off to school for the first time” “It’s like watching your kids go off to school for the first time” “Quite a bit of paperwork but was warned about it” “In the company of caring people” “Had impression that it would stat sooner” “In the company of caring people” “I can’t recall” “I can’t recall” “Lengthy wait” “Lengthy wait” “The trial visit took away some of the fear” “No start date given” “The trial visit took away some of the fear” “Something was possible “No start date given” “Something was possible “Given a time frame of 2 weeks to start” “Given a time frame of 2 weeks to start” ve -ve Helpful Relief Comfortable Prepared Love it Trepidation Disappointed Confused Miscommunication Impatient Anxious Very Pleased Warm Welcoming Friendly Hesitant Nervous

28 CAPTURE: A Variety of Methods for Capturing the ExperienceBreadth Interviews Shadowing/ Observation Filming/ Photography Storyboards Diaries Emotion questionnaire Focus groups Observation Depth © NHS Institute for Innovation and Improvement 2006

29 CAPTURE: Experience Questionnaire© NHS Institute for Innovation and Improvement 2006

30 Capture the ExperienceDidn’t know where I was going until I got here but the sun is shining in the room and I had a view! Everyone was positive; gave me their names and asked me what I wanted to be called Nurses went out of their way to help me get settled Knew I was coming 2 days in advance but no info was available Drowsy and dizzy while in hallway Not confident I can get up and walk; worried about falling – Friends went online to look BH up for me but I couldn’t see any of the rooms Has spinal stenosis – not tolerate long stretches lying flat – was waiting 3hrs for room Objectives: Capture and understand the staff and patient/family experience with the current admission process on one orthopedic unit. Engage patients and families together with staff in co-designing the first 48 hours of care, test and evaluate change ideas Implement and spread change ideas This mirrored the staff experience: Patients are not leaving on time i.e. before 10am Patients are waiting in the hallway > 1hr They are arriving before people leave Patients do not know how to prepare before they arrive

31 UNDERSTAND: Emotional mappingPatient goes to different department for investigations (X-Ray/ Pathology Patient registers with reception Patient waits to sees consultant Patient navigates to department Patient sees consultant Patient arrives at car park Patient navigates to clinic Patient arrives at clinic It took ages to find a car parking space and then I found it was a 15 minute walk to the outpatients clinic. How frustrating! I wasn’t sure where to go – the signs were difficult to follow. The room was cluttered with out of date magazines and notices on the walls and I was already feeling really nervous. +ve informed pleased relieved upset apprehensive anxious nervous frustrated frustrated angry worried anxious -ve © NHS Institute for Innovation and Improvement 2009

32 Capture & Understand: Sheila

33 Clinic Waiting Exam Room RoomFelt like appointment was just for her – nobody else Addressed by first name which I liked Positive Triggers Able to ask all the questions she wanted to Mr Chan said he knew all about me Kind people who said everything gently but professionally Clinic was indoors and couldn’t see outside Waiting from 11:00am to 12:50 for appointment Negative Triggers Saw people surgery on their voice boxes Valued Cared For Appreciated Positive Emotions Supported Welcomed Dreadful Terrible Negative Emotions Filled with horror

34 Samantha Davie, SMHAFHT

35 IMPROVE: Engage patients in solution generation and testing of change ideasPatients and family members bring new perspectives and these can be enhanced through idea generation sessions © NHS Institute for Innovation and Improvement 2006

36 Challenging Our ThinkingOur Co-Design Event 1. Pre-Admission Knowing what to expect 2. Admission Hallway Wait Patients & Families Physicians Patient Care Manager Clinical Leadership Support Staff Health Disciplines Nursing Challenging Our Thinking “Can we shift the burden of waiting?” Based on the feedback from staff and patients/families, we prioritized 2 major areas of focus for our co-design event.

37 Change Ideas 1. Knowing What To Expect 2. Discharge Tools Knowing what to expect: Change ideas Reviewed and revised website and admission pamphalet Provided an information session and tour of our facilities for our acute care partners: orthopedic surgeon’s offices Created a video describing our orthopedic program for our internet site 3. Shifting the burden of waiting outside a patient room , as necessary, to discharged patients

38 MEASURE: Use Quantitative Gold Standard

39 Measure the ImprovementProcess Measures Change Ideas Post-Implementation Knowing What to Expect Visits to the Orthopedic Program Video 761 visits Admission Hallway Wait # of patients waited in the hallway % of patients leaving between 830-9am 18%  Discharge slip 100% patients received Ready to go discharge checklist One of the main principles of quality improvement is to be able to measure for improvement over time to know whether the change was a successful one. We measured and evaluated through all of our PDSA cycles. We can confidently say that our change ideas were successful as we have been able to demonstrate improvements in both our process and outcome measures.

40 Measure the Improvement (Continue)Outcome Measures Pre-Implementation Post-Implementation Variance Patient Experience on Admission 67% 87% 20% Patient Experience – First 48 Hours 62% 100% 38% Patient Satisfaction for Continuity & Transition 72% (2014/15) 88% (YTD Feb 2016) 16% Hip Fracture LOS 28 days 21.6 days (Q3 2015/16) 7.6 days We have been able to demonstrate improvements in both of our QIP outcome indicators. 16% improvement in our patient satisfaction continuity & transition score 7.6 days improvement in our hip fracture LOS The LOS decrease is largely due to the orthopedic re-design work that was going on concurrently during the same time period. However, one of the main drivers from this project around LOS was that we were better preparing our patients for discharge. But also, patients who were being picked up by their families in the late afternoon/early evening, they were now leaving a day earlier, after therapy ends on the day before discharge. This is potentially saving us a day. With patients leaving the evening before the actual discharge day, we are able to clean and turn over the rooms in the evening.

41 Qualitative ApproachesBEFORE AFTER

42 Sample Quantitative Data (Sample Data)

43 EBD Data

45 How can the methodology be used?Supplement to Provider Mapping at the beginning of an Improvement Initiative Within the context of PDSA testing (Co-ordinated Care Plans, Case Conferences) Complaints Process Regular Measurement And more!!!

46 Contact Information Paula Blackstien-Hirsch Principal Telephone:

Improving the Patient Experience through Experience Based Design

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